OBJECTIVE:
To analyze how seasonal communication for dengue control and prevention is conveyed
in educational peer groups of Family Health teams.
METHODOLOGICAL PROCEDURES: An exploratory and descriptive qualitative study
was performed with 25 coordinators of peer education groups, distributed among
eight basic health units of Belo Horizonte, Southeastern Brazil. Data collection
occurred from March to June 2009, by non-participant observation and semi-structured
interviews with coordinators. Content analysis and the principal theories in
health communication were utilized in data interpretation.ANALYSIS OF RESULTS: Three thematic units were identified: seasonal communication;
subjects discussed and information sources about dengue; and information versus
communication for action. Dengue prevention and control actions were principally
discussed in groups during outbreaks, based on actions previously programmed
by the Ministry of Health. The topics addressed focused on epidemiology, life
cycle, modes of transmission, symptoms, prevention, domiciliary visits by zoonosis
control units and vaccination for dengue.CONCLUSIONS: The predominant communication action is information conveyance
by the coordinator, centered on a behavioralist and prescriptive discourse.
Communication practices focused on dialogue is recommended, allowing the coordinator
and group members freedom in regards to emergent issues in the group, so they
learn to recognize and reflexively discuss them in context.

Over the past decades,
dengue has become one of the primary epidemic diseases in developing countries,
with significant economic, social and public health impacts.ª

Annually an estimated
50 to 100 million new infections of dengue virus occur in the world.ª
In Brazil, in 2009, there were 2,271 confirmed cases of hemorrhagic dengue with
154 deaths.b

Community participation
in the elimination of dengue is fundamental, since studiesc
indicate that approximately 90% of mosquito breeding sites are inside homes.

Given this situation
the government has invested in integrated activities for health, education,
communication and social mobilization, starting with primary health care activities,d
especially Family Health.20 Peer education groups are emphasized
within the actions proposed for Family Health teams, and they promote community
participation to improve living conditions.14,25 Coordinators of
peer education groups must consider individual, cultural and social issues through
dialogue and face-to-face interaction between participants.13,19

Although educational
activities are a possibility for promotion of community mobilization to control
dengue,15,22 studies5,25 show they do not always result
in effective actions that reduce disease prevalence. This apparent paradox in
health education activities can be explained through the principal theories
of the health communication field. For example, part of the inefficiency of
these activities can be attributed to the manner people process the information
received.24

The strategy for
prevention and control of infectious parasitic diseases is characterized by
seasonal communication, defined as a communication strategy in accordance with
the most favorable season for the disease to spread, in order to meet epidemiological
priorities.e

In Brazil, information
about dengue circulates mostly in the summer. After the period of greatest mosquito
infestation, control measures have a reduced frequency and coverage, promoting
the false idea that dengue only occurs during the summer. Awareness of dengue
among the population increases during this period, without a respective decrease
in incidence rates from successive dengue epidemics.

Although it cannot
always control infectious parasitic diseases, seasonal communication is an important
strategy utilized in Brazilian public health efforts over the years. Expanded
use of seasonal communication potentially indicates that gradual interventions,
which are very different than traditional interventions, are being implemented.
For example, the dialogue model seeks participatory learning, promoting an iterative
process among multiple producers/receivers of messages.3

Continued seasonal
communication in these cases can harm other prevention initiatives, which possibly
complicates dengue control activities in Brazil. In addition, topics about communication
for the prevention and control of infectious parasitic diseases are still in
their initial stages. It is necessary to intensify and refine effectiveness
research of these communication activities.

Therefore, the
objective of this study was to analyze how seasonal communication occurs in
the peer education groups of Family Health teams, to prevent and control dengue.

METHODOLOGICAL
PROCEDURES

A descriptive and
exploratory qualitative study was carried out with 25 coordinators of peer groups,
active in eight basic health units of Belo Horizonte, Southeastern Brazil.

Inclusion criteria
for study informants included: member of a complete Family Health team (composed
of a physician, nurse, two nurse assistants); coordinator of a group that performs
educational activities; belonging to a group that includes at least one discussion
about dengue prevention and control; consent to participate in the study.

Data were collected
from March to June of 2009, first by non-participant observation of peer groups,
and subsequently by semi-structured interviews with coordinators.

The main themes
from the non-participant observation included: content discussed in each meeting;
sources for distribution of information; mediation techniques of the group coordinator;
important dialogues; and relationships established between the participants,
considering symbols, signs and discussions that indicate conversational competency.

Overall 33 meetings
were observed and recorded in a field diary with a continuous description of
verbal and non-verbal manifestations, and the observations lead to notes on
theory, methodology and content. The information was recorded by manual writing,
audio recording and data transcription.

Only coordinators
were interviewed since they were the group mediators,1 who organized
discussion topics and interfered in group conduct, questioning, analyzing and
interpreting group phenomenon. They appears to contribute to more or less participant
involvement concerning proposed objectives.

Fourteen people
were interviewed: one physician, five nurses, two nurse technicians, five community
health workers (CHW) and one social worker. Interviews were performed individually,
recorded in MP3 format and transcribed.

The original question
was "Tell me how communication occurs during group activities, considering themes
about the prevention and control of dengue". After the informant responded,
subsequent questions were asked to clarify some of the situations described.

Data collection
was finalized upon information saturation, when no new or relevant data was
encountered.17

The information
was organized and categorized using the thematic analysis proposed by Bardin.4
Following transcription of interviews and field observations, the material was
thoroughly reviewed for pre-analysis and data exploration. Then charts were
systematically organized and units of meaning recorded, with subsequent classification
by thematic area.

The principal theories
in health communication were utilized for data interpretation, in addition to
theories by Foucault, whose ideas facilitate the consideration of power and
knowledge within institutions.

The study was approved
by the Research Ethics Committee of the Federal University of Minas Gerais (Appearance
No. ETIC 133/08) and by the Ethics Committee of the Belo Horizonte Municipal
Health Secretary (Protocol 044/2008).f
Study participants, including participants of peer groups, signed a voluntary
informed consent form. To guarantee anonymity, participants were identified
by the letter C, for coordinator, and numbered according to the order contacted.

ANALYSIS OF
RESULTS AND DISCUSSION

The observed groups
were majority female (78.1%), age 60 years or more (73.4%). There were an average
of 18 participants per group, and groups met weekly (53.8%), biweekly (7.7%),
every two months (7.7%) or every three months (3.8%).

Seasonal communication

Among the groups
studied, themes concerning dengue control and prevention were principally discussed
during outbreak seasons, when community collaboration is sought:

"We lead some
themes to the given health topic, according to what is happening at that season".
(C1, nurse)

This same finding
was encountered in another study23 on health communication practices
for dengue prevention. Health professionals still adopt a communication model
for a single, time-limited, campaign that prioritizes epidemics, even though
it would be important to integrate dengue as a topic for health services throughout
the year. Foucault11 (2004) explains that in epidemics a breakthrough
occurs, so that the medical field adopts new discourse, behavior and goals so
that the subject of recognition is reorganized and modified, changing practice.

One of the factors
that interferes with adherence to preventive practices involves the lack of
a continuous mode of communication between the health service and community.5
The seasonal silence established by these groups presents a challenge for coordinators,
who must create space to stimulate continuous discussions of the public health
issues relevant in communities.

In order to encourage
community action during the groups, some coordinators co-opt members to participate
in campaigns against dengue during epidemic periods:

"C2 [CHW]
says that during Dengue Awareness Week, he considered the possibility of
the group doing something: 'I would like to see if you all become encouraged
to participate'. The group discusses about dengue activities, but does not make
any proposals. ACS remains silent. After some minutes, he interrupts the group
and says: 'I count on you'". (Observational notes)

Some factors influence
and determine the degree of individual participation in community actions, such
as social roles, manners to perceive and express values and the symbolic capital
of each participant.g

In addition, each
individual always occupies different places of conversation, does not presenting
the symbolic consumption of homogeneous and stable form, whose movements and
modes of appropriation and production of the senses constitute through diverse
interactive processes.3

Therefore, it is
important for the coordinator to recognize and consider these factors. The context
appears to favor the involvement of individuals in their comfort zone, represented
here by the initial decision of the coordinator, after the silence by participants,
to call the group to action.

Content discussed
and information channels

Group discussions
of dengue related to epidemiology, the vector life cycle, modes of transmission,
symptoms, prevention, household visits by the zoonosis team and vaccination.

"A participant
asks if only the female [mosquito] transmits dengue. C1 [nurse]
responds that yes: 'The female sucks blood to feed the eggs'. Towards to
the end of the group meeting, the nurse asks: 'What are the classic symptoms
of dengue?' The group responds: 'Pain and fever'". (Observation notes)

According to Foucault11
(2004), the goal in discussing an epidemic is not to abstractly recognize the
disease in a general manner. The task is to understand it within a given time
and space, which requires consideration of the issues that individual people
contemplate. Each person's manner of communication is dependent on institutions
and history, whose interactions determine the different ways people respond
to reality and encounter solutions for health problems. 3

During an epidemiologic
emergency, health education requires an exchange of knowledge through horizontal
interaction and requires consideration of participant needs rather than just
normalizing behaviors.

Within the Foucault
conception,11 what makes an epidemic a singular fact is consideration
of the context in which it occurs rather than the essence of the disease. Therefore,
the ability of the coordinator to communicate in the group depends on her capacity
to contextualize. Communication skills are related to identifying and assuming
the various contexts that constitute each situation.18

Communication in
groups was principally based on the actions programmed by the Brazilian Ministry
of Health and utilized campaign materials:

"C3 [nurse]
says they will address some questions about dengue. She distributed a pamphlet
by the Ministry of Health that emphasizes possible breeding location of the
vector mosquito. During the reading of the pamphlet, the nurse looks at the
members and makes comments. When a participant comments on an item, the nurse
does not explore the remark". (Observation notes)

In the passage
cited, some coordinators tend to view communication as a process to simply transmit
information from an emitter (coordinator) to a recipient (group members). Such
a model does not value the rest of the process, including the circulation of
messages and their appropriation by the different people involved.

The coordinators'
fundamental preoccupation is to maximize the transmission of messages to the
group and to limit possibilities for negotiation as well as creation of meaning.
According to some authors,g
this means limit the dimension of otherness that should accompany the concept
of communication if the paradigm that most approximates the principles of the
Family Health is the dialogue.

According to Freire13
(1971), for an act of communication to be efficient the subjects must also engage
in communication and the information must be understood within a meaningful
framework shared among the subjects. If these requirements do not occur, understanding
between the subjects will not exist and communication will be impossible.

The previously
described situations are not conducive to the creation of meaning within the
group, since some coordinators have difficulty to consider the prior experiences
of participants with the subject matter and to stimulate discussion. This style
of communication reproduces the hegemonic message of Brazilian health policy
and reinforces the central role of information transfer in campaigns that focus
on disseminating information about interventions to the community, with little
attention to the role of exchange and appropriation by recipients.e

Other authors2
criticize this type of educational approach because it cannot persuade and does
not align with the goal to spread information. The goal should be to at least
establish a public debate about the subject and guarantee sufficient information
for people to increase citizen participation in health policies.

Therefore, to increase
the impact of groups, we believe that the collective construction of educational
materials in accordance with the local reality would stimulate dialogue and
pluralistic practices. It is also essential for the coordinator to diagnose
and evaluate the models by which people attribute meaning and convert information
into action. The group coordinator would articulate a national proposal without
restricting the discussion and would favor a decentralized production and exchange
of ideas, thereby breaking the understanding that participation is synonymous
with adherence.

Information
versus communication for action

In order to make
the group more pro-active in its actions, some coordinators identify multipliers,
who through repeated communication are considered intermediaries in the communication
network. The two-step flow of communication reinforces the existence of intermediaries
between the source and recipient of messages, which impact the manner that recipients
understand. Although they are community members, the multipliers promote the
diffusion of information in a singular manner, imprinting their own meanings
to the content they spread.2

"You end up
creating multipliers. The neighbors, group participants, begin to feel responsible
for dengue. If the neighbor's water box is not covered, then I will report it".
(C7, nurse)

Foucault perceives9
individual constitutions as involved in historical processes of subjection involving
forms of power with an immediate influence in daily life that impact individuality.
Individual constitutions involve four central aspects: 1) behavior related to
conduct and how one understands how to be an active individual and their moral
substance; 2) the mode of subjection, which involves how people are described
or provoked when recognized as active; 3) ascension practices - a transformation
experienced by the individual to reach another way of being; 4) the type of
person they aspire to, when they behave as active subjects.12

Using these ideas,
acts and conduct are real behaviors of people in relation to norms imposed by
their culture, society and social group. Therefore, it may be argued that the
active subject is fabricated, as is the passive and docile subject. 10

No change occurs
without learning, since the two processes are interdependent. Nonetheless, there
is a distance between knowledge and attitude. Increased knowledge does not always
correspond to a behavior change in the population, which is the main goal of
dengue control measures.8

Various studies6,21
report a satisfactory level of knowledge from educational campaigns, in terms
of information transmission, but on the other hand, demonstrate a discrepancy
between knowledge and effective control of the illness.

Although health-related
norms and behaviors are mediated by culture, they are also very personal. Not
considering the irrationality of behavior choices may be the greatest shortcoming
in the practice of public health. It is therefore necessary to attempt to understand
the various determinants of human behavior.7 The attribution of meaning
in a given situation is influenced by the moment in which you live, by the external
dynamic represented by happenings in the world that in turn influence internal
dynamics.

Moreover, permanent
effort is required to place the main issues in the field of the values and symbolic
elements with which communities operate in constant attention to with the multiple
meanings that guide people's lives. Groups formed to take health action and
group leaders can strategically make such efforts.19

The effective control
of diseases, such as dengue, does not happen through vertical program, since
the disease involves aspects connected to the conditions and experiences of
communities that when neglected perceive social exclusion.21 Communication
should create references for action and individual behavior change, according
to personal and social knowledge and opinions. Communication efforts should
be diversified, personalized, local and culturally relevant so that learning
occurs through active comprehension of reality, based on community organization
and knowledge.h

The need to open
effective modes of communication in group processes should be emphasized. Effective
relationships between the coordinator and other group members are necessary,
as suggested by the ideas of cohesion and continuity.

CONCLUSIONS

A majority of communication
practices consisted of the coordinator transmitting information about dengue,
with a focus on behavior and prescriptive discourse. This vertical transmission
of knowledge contributes to establish distance between the participants. This
makes it difficult for participants to identify with the part of reality they
want to change, as active subjects who construct their lives within a sociocultural
context involving expectations, values, beliefs and specific habits.

Actions against
dengue require continuous activities that overcome promotion of behavior change
through the simple diffusion of information during outbreaks.5,6,8
Interaction and communication should be instead based on the reciprocal exchange
of ideas between coordinator and group members.

The vector is well-adapted
to the urban environment, and its control demands intersectoral actions involving,
culture, education, tourism, transportation, civil construction and basic sanitation.
It also requires involvement of the private sector and organized society, according
to larger notions of health that move beyond the simple idea of treatment.

It is fundamental
to consider the complex process of group communication. The focus should be
on training people so they know what to do with information. It is important
that the message communicated and the delivery method correspond to the needs
of participants, which would contribute to autonomy in group decision-making
and to transformation of reality.

Recognition of
the symbols and specific codes of the several identities in the group is essential
for effective group communication. Therefore, we recommend that communication
strategies focus on dialogue so that the coordinator and members have freedom
to discuss the problem and can learn to recognize it and understand it in a
critical and reflexive manner.